Upper Gastrointestinal Bleeding

What is Upper Gastrointestinal Bleeding

Upper gastrointestinal bleeding is bleeding from the swallowing tube (esophagus), stomach, or the first part of the small intestine (duodenum). If you have upper GI bleeding, you may vomit blood or have bloody or black stools.

Bleeding can range from mild to serious or even life-threatening. If there is a lot of bleeding, you may need to stay in the hospital.

What are the major sources of upper gastrointestinal bleeding? 

The most common source of UGI bleeding is peptic ulcer disease, which accounts for 30% to 60% of cases, followed by esophageal varices, which account for 10% to 15% of cases. Other less common sources include esophagitis, angiodysplasia, Mallory-Weiss tears, cancer, gastric varices, portal hypertensive gastropathy, Dieulafoy lesions, and aortoenteric fistulas.

Causes of upper gastrointestinal bleeding

This condition may be caused by:

• Ulcer disease of the stomach (peptic ulcer) or duodenum. This is the most common cause of GI bleeding.
• Inflammation, irritation, or swelling of the esophagus (esophagitis).
• A tear in the esophagus.
• Cancer of the esophagus, stomach, or duodenum.
• An abnormal or weakened blood vessel in one of the upper GI structures.
• A bleeding disorder that impairs the formation of blood clots and causes easy bleeding (coagulopathy).

What increases the risk?

The following factors may make you more likely to develop this condition:

• Being older than 60 years of age.
• Being male.
• Having another long-term disease, especially liver or kidney disease.
• Having a stomach infection caused by Helicobacter pylori bacteria.
• Having frequent or severe vomiting.
• Abusing alcohol.
• Taking certain medicines for a long time, such as:
  • NSAIDs.
  • Anticoagulants.

What are the signs or symptoms?

Symptoms of this condition include:

• Vomiting blood.
• Black or maroon-colored stools.
• Bloody stools.
• Weakness or dizziness.
• Heartburn.
• Abdominal pain.
• Difficulty swallowing.
• Weight loss.
• Yellow eyes or skin (jaundice).
• Racing heartbeat.

What are the signs, symptoms, and risk factors of UGI bleeding? 

Patients with UGI bleeding typically present with melena (black, tarry stool), although melena is occasionally seen in patients with right-sided colonic bleeding. Hematemesis or coffee-ground emesis is also a common presentation of UGI bleeding. Patients with massive UGI bleeding present with hematochezia together with hemodynamic instability that can be mistaken for lower GI bleeding. 

The below table summarizes important presenting features in patients with UGI bleeding.

Risk Factors, Symptoms, and Signs of UGI Bleeding

Risk Factors	History	Examination
Medications (aspirin, NSAIDs, corticosteroids) Stress (trauma, burns, CNS injury) Alcohol abuse Chronic liver disease Helicobacter pylori infection	Melena Hematemesis Hematochezia Dizziness Syncope Acid reflux (esophagitis) Dyspepsia Vomiting prior to bleeding episode (Mallory-Weiss tear) Aortic aneurysm repair (aortoenteric fistula) Prior UGI bleeding	Orthostasis Tachycardia Hypotension Melena or hematochezia on rectal examination Nasogastric tube aspirate positive for blood or “coffee grounds” Abdominal tenderness Stigmata of chronic liver disease

CNS, Central nervous system; NSAID, nonsteroidal antiinflammatory drug; UGI, upper gastrointestinal.

What features on presentation can be used to predict the severity of UGI bleeding? 

A number of scoring systems have been developed to predict the likelihood of adverse outcomes and need for intervention. The most commonly used are the Blatchford score, the Rockall score, and the AIMS65 score. These scores can be used to triage patients to appropriate levels of care, including urgent endoscopy and early discharge. In general, the higher the number of risk factors, the higher the risk of adverse outcome.

The Blatchford Score

Clinical Parameters at Presentation	Score
Systolic blood pressure (mm Hg)
≥ 110 100 to 109 90 to 99 < 90	0 1 2 3
Blood urea nitrogen (mg/dL)
< 18 18 to 22 22 to 28 28 to 69 > 70	0 2 3 4 6
Hemoglobin for men (g/dL)
≥ 13 12 to 12.9 10 to 11.9 < 10	0 1 3 6
Hemoglobin for women (g/dL)
≥ 12 10 to 11.9 < 10	0 1 6
Other variables at presentation
Pulse > 100 Melena Syncope Hepatic disease Cardiac failure	1 1 2 2 2
Maximum score	23

The risk of requiring endoscopic intervention increases with a higher score. A Blatchford score of zero was associated with a low likelihood of the need for urgent endoscopic intervention.

The Rockall Score

Variable	Score
Age (yr)
< 60 60 to 79 > 80	0 1 2
Shock
Normal heart rate and blood pressure Heart rate > 100 bpm Systolic blood pressure < 100 mm Hg	0 1 2
Coexisting illness
No major illness Ischemic heart disease, congestive heart failure Renal failure, hepatic failure, metastatic cancer, other major illness	0 2 3
Endoscopic diagnosis
No lesion observed, Mallory-Weiss tear (without stigmata) Nonmalignant lesion Cancer of upper GI tract	0 1 2
Endoscopic stigmata of recent hemorrhage
Clean base ulcer, flat pigmented spot Blood in upper GI tract, active bleeding, visible vessel, clot	0 2
Maximum score	11

bpm, Beats per minute; GI, gastrointestinal.The clinical Rockall score includes age, shock, and coexisting illness. The complete Rockall score includes the clinical Rockall score plus endoscopic score. Patient with a clinical Rockall score of 0 or a complete Rockall score or less than or equal to 2 are considered low risk for rebleeding or death.

AIMS65 Score

Risk Factor	Score
Albumin < 3 mg/dL	1
INR > 1.5	1
Altered mental status	1
SBP < 90 mm Hg	1
Age > 65	1
Maximum score	5

INR, International normalized ratio; SBP, systolic blood pressure.As the number of risk factors accumulate, length of hospital stay, cost, and mortality increases (e.g., no risk factors: 0.3% mortality; one risk factor: 1%; two risk factors: 3%; three risk factors: 9%; four risk factors: 15%; and five risk factors: 25%).

What is the role of aspirin and nonsteroidal antiinflammatory drugs (NSAIDs) in UGI bleeding? 

Regular aspirin and NSAID use increases the risk of major gastrointestinal (GI) bleeding (relative risk for aspirin is 1.4). Bleeding risk is highly related to dose, but even low-dose aspirin can result in GI bleeding. Risk factors for NSAID-related UGI bleeding include age older than 65 years; a history of peptic ulcers; and use of concomitant platelet P2Y12 inhibitors, anticoagulants, or corticosteroids.

How to distinguish a UGI bleed from a lower GI bleed in a patient who presents with blood per rectum? 

The feature most suggestive of UGI bleed rather than lower GI bleed is melenic stool on rectal examination (likelihood ratio [LR] 25). Other features suggestive of a UGI bleed rather than lower GI bleed include a blood urea nitrogen/creatinine ratio of more than 30 (LR 7.5), and a report of melena (5.1-5.9). Hematochezia (red or maroon stool) generally indicates a lower GI bleed, and the presence of blood clots in the stool decreases the likelihood of an UGI bleed (LR 0.05). Patients with hematochezia from a UGI source present with hemodynamic compromise.

How is this diagnosed?

This condition may be diagnosed based on:

• Your symptoms and medical history.
• A physical exam. During the exam, your health care provider will check for signs of blood loss, such as low blood pressure and a rapid pulse.
• Tests, such as:
  • Blood tests to measure your blood cell count and to check for other signs of blood loss and clotting ability.
  • Blood tests to check your liver and kidney function.
  • A chest X-ray to look for a tear in the esophagus.
  • Endoscopy. In this procedure, a flexible scope is put down your esophagus and into your stomach or duodenum to look for the source of bleeding.
  • Angiogram. This may be done if the source of bleeding is not found during endoscopy. For an angiogram, X-rays are taken after a dye is injected into your bloodstream.
  • Nasogastric tube insertion. This is a tube passed through your nose and down into your stomach. It may be connected to a source of gentle suction to see if any blood comes out.

When to suspect a variceal bleed? 

Risk factors for chronic liver disease (e.g., excessive alcohol use, viral hepatitis), stigmata of chronic liver disease on physical examination (e.g., spider angiomata, palmar erythema, jaundice), and hematemesis, with hematochezia and hemodynamic compromise, make a variceal bleed more likely. It is important to remember that patients with cirrhosis are at risk of bleeding from nonvariceal sources, which collectively account for approximately 50% of UGI bleeds in patients with cirrhosis.

How can the amount of acute blood losts be estimated clinically? 

As little as 50 mL of blood can produce melenic stool. The acute loss of 500 mL of blood will not result in detectable physiologic changes. Mild to moderate blood loss (500-1000 mL) results in resting tachycardia, whereas loss of 1000 mL will produce orthostatic changes. Loss of 2000 mL or more of blood will produce shock. The hematocrit at the time of presentation may not reflect blood loss. A fall in hematocrit is seen over time with fluid resuscitation or replacement of volume with extravascular fluid.

How is this treated?

Treatment for this condition depends on the cause of the bleeding. Active bleeding is treated at the hospital. Treatment may include:

• Getting fluids through an IV tube inserted into one of your veins.
• Getting blood through an IV tube (blood transfusion).
• Getting high doses of medicine through the IV to lower stomach acid. This may be done to treat ulcer disease.
• Having endoscopy to treat an area of bleeding with high heat (coagulation), injections, or surgical clips.
• Having a procedure that involves first doing an angiogram and then blocking blood flow to the bleeding site (embolization).
• Stopping or changing some of your regular medicines for a certain amount of time.
• Having other surgical procedures if initial treatments do not control bleeding.

What are the first steps in managing a patient with UGI bleeding? 

Patient evaluation and resuscitation are the first steps in managing UGI bleeding. Patients should have two large-bore peripheral intravenous (IV) catheters or a central venous line if indicated. Patients with active bleeding or hemodynamic instability should receive volume replacement, initially with crystalloid, to stabilize blood pressure and heart rate. Laboratories including a complete blood count, creatinine and blood urea nitrogen, prothrombin time, and partial thromboplastin time should be obtained. Patients with active bleeding should be typed and cross-matched for packed red blood cell transfusion. Clotting abnormalities and anemia need correcting in certain patients 

What is the goal hemoglobin in patients with UGI bleeding? 

The hemoglobin goal in UGI bleed is uncertain. However, a restrictive transfusion strategy (when hemoglobin < 7 g/dL) compared with a liberal transfusion strategy (when hemoglobin < 9 g/dL) has been recently found to improve rebleeding and mortality rates in patients with peptic ulcer bleeding or variceal bleeding with Child-Pugh A or B cirrhosis who underwent emergent upper endoscopy with endoscopic treatment. However, patients with brisk bleeding resulting in shock and patients with significant comorbid illness, particularly cardiovascular, cerebrovascular, or peripheral vascular disease, should be transfused more aggressively (goal hemoglobin 9 g/dL).

What is the goal INR and platelet count in patients with UGI bleeding? 

Conventionally, a goal INR of less than 1.5 to 2 and a platelet count of more than 50,000 are recommended prior to endoscopy. However, guidelines recommend that endoscopy should not be delayed for correction of coagulopathy.

Should a nasogastric (NG) tube be placed in patients with suspected UGI bleeding? 

A bloody NG lavage increases the likelihood of severe bleeding or finding active bleeding or a nonbleeding visible vessel at the time of endoscopy. However, NG lavage is generally not necessary for diagnosis, prognosis, or visualization, and is very uncomfortable for patients. Therefore it is not routinely recommended in patients with suspected UGI bleeding.

When should patients receive follow up after their episode of UGI bleeding? 

A visit with a primary care physician within 1 to 2 weeks of discharge can be considered to screen for recurrent bleeding and reinforce medical management. Gastric ulcers, if not initially biopsied on the index endoscopy, require a follow-up EGD in 6 to 8 weeks to ensure complete endoscopic healing and to exclude gastric cancer. Patients with esophageal varices are seen for repeat EBL every 1 to 3 weeks until the varices are eradicated.

Follow these instructions at home:

• Take over-the-counter and prescription medicines only as told by your health care provider. You may need to avoid NSAIDs or other medicines that increase bleeding.
• Do not drink alcohol.
• Drink enough fluid to keep your urine clear or pale yellow.
• Follow instructions from your health care provider about eating or drinking restrictions.
• Return to your normal activities as told by your health care provider. Ask your health care provider what activities are safe for you.
• Do not use any tobacco products, such as cigarettes, chewing tobacco, and e-cigarettes. If you need help quitting, ask your health care provider.
• Keep all follow-up visits as told by your health care provider. This is important.

Contact a health care provider if:

• You have abdominal pain or heartburn.
• You have unexplained weight loss.
• You have trouble swallowing.
• You have frequent vomiting.
• You develop jaundice.
• You feel weak or dizzy.
• You need help to stop smoking or drinking alcohol.

Get help right away if:

• You have vomiting with blood.
• You have blood in your stools.
• You have severe cramps in your back or abdomen.
• Your symptoms of upper GI bleeding come back after treatment.

Sources

• Adapted from Blatchford O, et al. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000;356:1318–1321.
• Adapted from Rockall TA, et al. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996;38:316–321.
• Adapted from Saltzman JR, et al. A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding. Gastrointest Endosc 2011;74(6):1215–1224.